In today’s digital age, encoded data can sometimes cause a snarl on the information highway. Prior to 2004, health care providers used different identifying numbers for themselves when they transmitted health care data online to facilitate patient records among various health plans. Without a standardized system of assigning a single identifying number that each health care provider could use across the board with all its health plans, transmitting data online this way caused lots of digital traffic jams. The introduction of National Provider Identifier (NPI) numbers in 2004 provided this much-needed standard.
Tips
NPI numbers are unique 10-digit identifiers for health care providers.
National Provider Identifier Numbers
NPI numbers identify each health care provider without providing additional information such as where the provider is located or the type of health care provided. NPI numbers represent the standard health care provider identifying system that the U.S. Department of Health and Human Services (HHS) began using under the Health Insurance Portability and Accountability Act (HIPAA). All HIPAA-covered health care providers as well as those who electronically file claims or digitally bill insurance carriers are required to have an NPI. Although other types of health care providers are not required to have an NPI, they may obtain one if they wish.
Uses for the NPI Number
In addition to its use in HIPAA-related electronic transactions, the HHS identifies other uses for the NPI number:
- For identifying health care providers on HIPAA-related correspondence.
- For health care providers to identify themselves in transactions or on correspondence with other health care providers.
- For health care providers to identify themselves on prescriptions, without replacing the Drug Enforcement Administration’s requirements or a state license number.
- For health plan administrators to use in their internal provider files in processing transactions and communicating with health care providers.
- For health plan administrators when coordinating other health plan benefits.
- For health care clearinghouses to use in their internal files for creating and processing certain transactions and communicating with health care plan providers.
- By digital patient record systems for identifying health care providers in a patient’s medical records.
- For HHS in cross-referencing fraudulent health care providers and identifying other compromises to program integrity files.
- For identifying health care providers in numerous legal pursuits, including the Debt Collection Improvement Act of 1996 and the Balanced Budget Act of 1997.
Who Must Have an NPI?
The HHS defines three types of HIPAA-covered entities: health care providers that make certain electronically transmitted transactions, health care clearinghouses and health plans such as Medicare, Medicaid and commercial plans. Even HIPAA-covered health care providers who do not electronically transmit their own data must have an NPI number (for example, these providers task a business associate to do this).
HHS further defines two categories of health care providers, which are HIPAA-covered entities, that must have an NPI – individuals (Entity Type 1) and organizations (Entity Type 2).
- Entity Type 1 – individual health care providers. This category also includes sole proprietors, who must apply for their NPI by using their Social Security number (SSN) instead of an employer identification number (EIN). Examples include physicians, dentists, nurses, chiropractors, physical therapists and pharmacists.
- Entity Type 2 – organization health care providers. An organization may be comprised of only one employee, such as an incorporated individual, or thousands of employees. Examples include group practices, clinics, hospitals, pharmacies, nursing homes, health maintenance organizations (HMOs), home health agencies (HHA) and residential treatment centers.
Obtaining an NPI Number
HIPAA-covered entities, whether they’re individuals or organizations, must apply for their NPIs through the Centers for Medicare and Medicaid Services (CMS) National Plan and Provider Enumeration System (NPPES). After an entity receives its NPI, the HHS publishes the health care provider’s name, address and specialty under its NPI number, in accordance with federal law.
References
- Department of Health and Human Services: NPI - What You Need to Know
- American Speech-Language-Hearing Association: National Provider Identifier (NPI) Numbers
- U.S. Department of Health & Human Services: Frequently Asked Questions About the National Provider Identifier (NPI)
- NPPES NPI Registry: Search NPI Records
- Centers for Medicare and Medicaid Services. "National Health Expenditures 2018 Highlights." Accessed Oct. 16, 2020.
- Centers for Disease Control and Prevention. "Table 94 (Page 1 of 2). National Health Expenditures, Average Annual Percent Change, and Percent Distribution, by Type of Expenditure: United States, Selected Years 1960–2015." Accessed Oct. 16, 2020.
- Health Affairs. "It’s the Prices, Stupid: Why the United States Is So Different From Other Countries." Accessed Oct. 16, 2020.
- OCEDiLibrary. "Comparing Price Levels of Hospital Services Across Countries." Accessed Oct. 16, 2020.
- Centers for Disease Control and Prevention. "Chronic Diseases in America." Accessed Oct. 16, 2020.
- Peterson-KFF. "How Do Health Expenditures Vary Across the Population?" Accessed Oct. 16, 2020.
- National Center for Biotechnology Information. "Long-Term Trends in Medicare Payments in the Last Year of Life." Accessed Oct. 16, 2020.
- Centers for Medicare and Medicaid Services. "History of Health Spending in the United States, 1960-2013," Page 7. Accessed Oct. 16, 2020.
- Centers for Disease Control and Prevention. "Emergency Department Use in the Country’s Five Most Populous States and the Total United States, 2012." Accessed Oct. 16, 2020.
- Govinfo. "Public Law 93-222-DEC. 29, 1973." Accessed Oct. 16, 2020.
- Centers for Medicare and Medicaid Services. "History of Health Spending in the United States, 1960-2013," Pages 7-25. Accessed Oct. 16, 2020.
- Centers for Medicare and Medicaid Services. "Emergency Medical Treatment & Labor Act (EMTALA)." Accessed Oct. 16, 2020.
- Centers for Medicare and Medicaid Services. "History of Health Spending in the United States, 1960-2013," Pages 17, 33. Accessed Oct. 16, 2020.
- Health Affairs. "Direct-to-Consumer Prescription Drug Advertising: Trends, Impact, And Implications." Accessed Oct. 16, 2020.
- Centers for Medicare and Medicaid Services. "History of Health Spending in the United States, 1960-2013," Pages 18-22. Accessed Oct. 16, 2020.
- Health Affairs. "Prescription Drug Spending Trends in the United States: Looking Beyond the Turning Point." Accessed Oct. 16, 2020.
- Kaiser Family Foundation. "A Dozen Facts About Medicare Advantage in 2019." Accessed Oct. 16, 2020.
- National Center for Biotechnology Information. "Medicare Modernization: The New Prescription Drug Benefit and Redesigned Part B and Part C." Accessed Oct. 16, 2020.
- The New England Journal of Medicine. "Costs of Health Care Administration in the United States and Canada." Accessed Oct. 16, 2020.
- Health Affairs. "Saving Billions of Dollars—and Physicians’ Time—by Streamlining Billing Practices." Accessed Oct. 16, 2020.
- Centers for Disease Control and Prevention. "Emergency Room Use Among Adults Aged 18–64: Early Release of Estimates From the National Health Interview Survey, January–June 2011." Accessed Oct. 16, 2020.
- American Hospital Association. "Uncompensated Care Cost Fact Sheet," Page 3. Accessed Oct. 16, 2020.
- Centers for Disease Control and Prevention. "Leading Causes of Death." Accessed Oct. 16, 2020.
- Centers for Disease Control and Prevention. "National Diabetes Statistics Report, 2020," Page 13. Accessed Oct. 16, 2020.
- National Academies Press. "5 Options for Medicare and Medicaid." Accessed Oct. 16, 2020.
- Federation of American Scientists. "Mandatory Spending Since 1962," Page 7. Accessed Oct.16, 2020.
- Health Affairs. "National Health Care Spending in 2016: Spending and Enrollment Growth Slow After Initial Coverage Expansions." Accessed Oct. 16, 2020.
- Kaiser Family Foundation. "The Mystery of the Missing $1,200 Per Person: Can Medicare’s Spending Slowdown Continue?" Accessed Oct. 16, 2020.
- Health Affairs. "Recent Growth in Medicare Advantage Enrollment Associated With Decreased Fee-for-Service Spending in Certain US Counties." Accessed Oct.16, 2020.
- National Center for Biotechnology Information. "Hospital Readmissions Reduction Program." Accessed Oct. 16, 2020.
- Kaiser Family Foundation. "The Facts on Medicare Spending and Financing." Accessed Oct. 16, 2020.
- Centers for Medicare and Medicaid Services. "Historical," Download "NHE Summary, including share of GDP, CY 1960-2018 (ZIP)." Accessed Oct. 16, 2020.
- California Health Care Foundation. "Infographic — US Health Care Spending: Who Pays?" Accessed Oct. 16, 2020.
Writer Bio
Victoria Lee Blackstone was formerly with Freddie Mac’s mortgage acquisition department, where she funded multi-million-dollar loan pools for primary lending institutions, worked on a mortgage fraud task force and wrote the convertible ARM section of the company’s policies and procedures manual. Currently, Blackstone is a professional writer with expertise in the fields of mortgage, finance, budgeting and tax. She is the author of more than 2,000 published works for newspapers, magazines, online publications and individual clients.